In light of the fact that federal funding for the Children’s Health Insurance Program (CHIP) expired on September 30, 2017, the Kaiser Family Foundation (KFF) analyzed the impact upon states and potential outcomes. Without an extension of federal funding for CHIP, KFF reported that states have or will run out of federal CHIP funding and may face budget shortfalls for CHIP, which covered 8.9 million children in 2016.

According to KFF under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) the enhanced federal funding matching rate was further increased by 23 percent. With this, the CHIP federal matching rate ranged from 88 percent to 100 percent. Because nearly all the states included federal funding for CHIP when creating their FY 2018 state budgets, nearly all the states will face a budget shortfall if the federal funding is not extended.

In the absence of an extension of federal funding for CHIP, some states will have to reduce CHIP coverage. States that have CHIP-funded Medicaid expansions must maintain the underage under the ACA “maintenance of effort” requirement, leaving state costs to increase in the face of lower federal Medicaid match rate. However, states with separate CHIP coverage are not required to maintain it, and states may freeze enrollment or discontinue CHIP coverage altogether.

In the short run, states can continue to use federal funding accrued through the September 30 expiration. Eleven states reported that they would run out of federal funding for CHIP by the end of FY 2017, and at least one state reported that their funding would be depleted at the expiration date. By redistribution of unspent CHIP funds, the Centers for Medicare and Medicaid Services (CMS) was able to provide enough additional funding to allow that state to maintain coverage without a budget shortfall through October. CMS was also able to provide redistributed funds to several other states that were close to running out of funds.

In order to address the expected states’ budget shortfalls, Congress is working on legislation for continued funding. Both the Senate and the House have reported bills out of committee to provide an extension of federal funding for CHIP. The bills from the House and Senate contain many of the same provisions, including a five-year extension for federal funding of CHIP and a transition down from the enhanced 23 percent match provided by the ACA. However, the House bill includes some additional provisions not included in the Senate bill. Both bills still need to be debated and voted upon by the full House and Senate, and if both are passed, Congress will have to reconcile the difference between the two bills.

Without congressional action, authorization for the Children’s Health Insurance Program will end on September 30, 2017, with the end of fiscal year (FY) 2017. Cuts to disproportionate share hospital (DSH) payments are also scheduled to take effect on October 1, 2017. If the authorization lapses and the cuts take effect, states will face budget shortages in their attempts to keep the CHIP program solvent and DSHs, which already operate on tight budgets, will be exposed to greater financial strain. A number of other health care related provisions are also slated to lapse on September 30, 2017, if Congress does not act, according to a Congressional Research Service (CSR) report.

Action

On September 28, 2017, the Energy and Commerce Committee announced that it would markup a bill to extend funding to the CHIP program. On the same day, members of Congress authored a letter to House Speaker Paul Ryan (R-Wis) and Democratic Leader Nancy Pelosi (D-Calif) expressing concerns regarding the impact of the DSH cuts and calling for congressional action.

DSH cuts

Stakeholders have made ongoing attempts to procure action from Congress to delay the DSH cuts. On September 18, nine hospital organizations urged lawmakers to further delay the start of Medicaid DSH cuts authorized by Section 2551 of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) (see Hospital organizations again advocate for delay of Medicaid DSH reductions, September 19, 2017). The cuts would have gone into effect in 2014 but legislation delayed the reduction. The reduced payments were designed to account for decreases in uncompensated care, yet, DSHs warn that planned increases in coverage rates under the ACA have not been realized, exposing providers to unfair payment reductions.

CHIP

Although the impact of a delay in CHIP reauthorization will differ from state to state, a Kaiser Family Foundation analysis revealed that “states would face budget pressures, children would lose coverage, and implementation of program changes could result in increased costs and administrative burden for states” if Congress does not reauthorize the CHIP program by the end of FY 2017 (see States face budget shortages if Congress doesn’t extend CHIP funding, September 11, 2017).

“Without federal funding [for the Children’s Health Insurance Program (CHIP)], states would face budget pressures, children would lose coverage, and implementation of program changes could result in increased costs and administrative burden for states as well as confusion for families,” according to a Kaiser Family Foundation (KFF) report published on September 6, 2017. Federal funding for CHIP is set to expire on September 30, 2017. The KFF report provides an overview of states’ plans for CHIP in light of the uncertainty about the future of federal funding and describes how the lack of federal funding will impact states and how children and their families will be affected.

States’ CHIP programs

States can provide CHIP through a separate CHIP program, a CHIP-funded Medicaid expansion, or a combination of the two approaches. If federal funding ends, states with separate CHIP coverage would not be required to maintain coverage. Under the Patient Protection and Affordable Act (ACA) (P.L. 111-148); however, states with CHIP-funded Medicaid expansions or a combination of both approaches would be required to maintain this coverage under the maintenance of effort requirement (see ACA sections 2001, 2101, 10203). Without federal funding, states’ costs would increase, KFF predicted.

Findings from surveys of states

KFF and Health Management Associates surveyed state Medicaid officials about their current budgets and their future plans for the CHIP program.In addition, KFF, along with the Georgetown University Center for Children and Families, conducted interviews with several state CHIP directors.

Key findings include:

Forty-eight out of 50 responding states, including the District of Columbia, assumed continuation of federal CHIP funding in the fiscal year (FY) state budgets. Thirty-four states assumed the funding would continue with the 23% enhancement that was included in the ACA.

Because states assumed continued federal funding in their state budgets, the majority of the states will face a funding shortage if federal funding is not extended. KFF noted that because state budgets have passed, addressing shortfalls will likely require special legislative sessions and/or governor action. Challenges include replacing federal dollars, costs of implementing program changes as well as system changes, outreach and training costs, and costs to close out the program.

Ten states estimated that they would exhaust their FY 2017 CHIP allotment by the end of 2017. Thirty-two states projected they will exhaust their federal funding at the end of March of 2018.

The majority of states have not developed plans for actions they would take if Congress does not extend funding but some plan to close or cap enrollment and/or discontinue coverage for children in separate CHIP programs. A few states have state statutes that require them to close CHIP and discontinue coverage if federal funds for CHIP decrease. In a few states, CHIP-funded coverage for other groups such as pregnant women and children in buy-in programs would be at risk for cutbacks.

Impact of loss of CHIP coverage

If states close enrollment or discontinue coverage for children in separate CHIP programs, some children would be uninsured but others could shift to parents’ employer-sponsored plans or Marketplaces plans. Previous enrollment caps and freezes that were a result of state budget pressures, led to coverage losses, left eligible individuals without access to coverage and had negative effects on children’s health and family finances, according to KFF. When enrollment was frozen in Arizona, some children were moved to Medicaid, but six in ten likely were uninsured and the uninsured rate grew following the freeze. In North Carolina, the number of children placed on a waiting list rose to over 34,000. Parents with children affected by the freeze reported that the children needed care during the period they were uninsured. They reported delaying or difficulty in obtaining care for the children, difficulties in obtaining prescription medications for their children, and significant financial hardships.

Actions to prepare for lack of federal funding

States need sufficient time to notify families and other stakeholders of the changes in coverage, make changes to eligibility systems, and train eligibility workers. They must also update contracts with managed care plans and third party administrators and submit necessary state plan amendments. States also must be aware that the steps they take to prepare and costs that they incur may be wasted if they begin to implement the change and Congress takes action after the deadline to extend funding.

CMS finalized changes to the Payment Error Rate Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) programs designed to improve payment oversight and state eligibility determinations in the Medicaid program. The changes—contained in an advance release of a Final rule set to publish in the Federal Register on July 5, 2017—implement provisions of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The Final rule ends a pilot phase for the two programs and resumes the eligibility measurement component of the PERM program and the MEQC program for Fiscal Year (FY) 2019.

PERM

The PERM program measures improper payments in Medicaid and the Children’s Health Insurance Program (CHIP) based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP. Due to changes in Medicaid eligibility law—including expansion under the ACA—CMS did not conduct the eligibility measurement component of the PERM program for FYs 2015 through 2018 (see CMS proposes updates to Medicaid eligibility and payment oversight, June 21, 2016). During that time, CMS conducted a pilot program known as the Medicaid and CHIP Eligibility Review Pilots to maintain oversight of state eligibility determinations. In addition to reestablishing the eligibility measurement component of the PERM program for FY 2019, the Final rule makes several updates to program requirements. Changes to the program include:

eligibility reviews for payments made by states between July and June of a given year (a change from the previous October through September review period);

federal contractor review of determinations;

sampled reviews based upon FFS and managed care payments;

inclusion of federal improper payments when the federal share is incorrect, even if the total computed amount is accurate;

the development of a national sample size; and

payment reductions in cases where a state’s eligibility improper payment rate exceeds the 3 percent threshold and the state does not demonstrate a good faith effort to meet the threshold.

MEQC

The MEQC program requires states to report to HHS the ratio of erroneous excess medical assistance payments to total expenditures for medical assistance. Under Section 1903(u) of the Social Security Act (SSA), HHS is required to withhold payments in excess of a 3 percent threshold for eligibility-related improper payments. Like the PERM program, CMS did not operate the MEQC program for FY 2015 through 2018 so that CMS could make updates to the program to reflect changes in eligibility. The Final rule aims to restructure the MEQC program to better compliment the PERM program. The changes include:

state flexibility to design MEQC programs unless states have consecutive improper payment rates over the 3 percent threshold;

requirements to conduct reviews beyond the scope of the PERM program; and